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Preventing Transmission at the Port-of-Entry: Risk Reduction Practices in the ED · The SHEA Podcast

• 0:08
  SPEAKER_01: Welcome to the Developments and Transmission-Based Precautions Podcast Series, brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:23
  SPEAKER_01: I am Chad Nix, an emergency medicine-bound fourth-year medical student at Oregon Health and Science University, or OHSU, and former infection preventionist, and I will serve as today's moderator.
• 0:32
  SPEAKER_01: Shay is excited to launch this episode entitled Preventing Transmission at the Port of Entry: Risk Reduction Practices in the ED.
• 0:38
  SPEAKER_01: I'm happy to introduce our speakers.
• 0:40
  SPEAKER_01: First, we have John Towns.
• 0:42
  SPEAKER_01: Dr.
• 0:42
  SPEAKER_01: Towns graduated from the Johns Hopkins School of Medicine and completed residency in intramedicine at the Johns Hopkins Hospital.
• 0:48
  SPEAKER_01: He served as Epidemic Intelligence Service Officer in the Foodborne and Diarrheal Diseases Branch at the CDC, and then completed a fellowship in infectious diseases at Vanderbilt University Hospital.
• 0:58
  SPEAKER_01: He joined the Infectious Diseases Division faculty at OHSU in 2000, where he's currently a professor of medicine and the medical director of infection prevention and control for OHSU Healthcare.
• 1:08
  SPEAKER_00: Hello, I'm happy to be here.
• 1:10
  SPEAKER_01: Next, we have Anna Yafee, Associate Professor of Emergency Medicine practicing clinically at Grady Memorial and Emory University Hospitals.
• 1:18
  SPEAKER_01: Dr.
• 1:18
  SPEAKER_01: Yafe serves as the Emergency Medicine liaison to the Emory Serious Communicable Diseases Unit and assists with frontline serious communicable disease preparedness for the Emory Healthcare System, as well as nationally through the National Emerging Special Pathogens Training and Education Center.
• 1:33
  SPEAKER_01: Dr.
• 1:33
  SPEAKER_01: Yafe received an MD and MPH from the University of Michigan, Ann Arbor, and completed her emergency medicine residency and chief residency at Emory University.
• 1:41
  SPEAKER_01: Before returning to Emory as faculty, Dr.
• 1:44
  SPEAKER_01: Yafe served as a lieutenant commander in the United States Public Health Service and worked as an epidemic intelligence service officer for the Centers for Disease Control and Prevention.
• 1:52
  SPEAKER_02: Hey everybody.
• 1:53
  SPEAKER_01: Thank you both for joining us.
• 1:55
  SPEAKER_01: Let's jump in.
• 1:56
  SPEAKER_01: Our patients ask questions at triage aimed at identifying the history of or risk factors for any pathogens of public health significance at your institution.
• 2:04
  SPEAKER_01: Anna, would you like to begin?
• 2:06
  SPEAKER_02: Yeah, absolutely.
• 2:08
  SPEAKER_02: Thanks so much for allowing me to be here to chat with you today.
• 2:11
  SPEAKER_02: As a frontline provider myself, I'm really excited that this topic is being focused on for the emergency department because I do think it's really important.
• 2:21
  SPEAKER_02: So certainly we do have some questions in our emergency department triage to identify history and risk factors for patients for having pathogens, specifically pathogens that have potential for transmission in our emergency department.
• 2:36
  SPEAKER_02: So, for example, we utilize a universal symptom screen.
• 2:40
  SPEAKER_02: So we ask patients if they've had cough fever or rash in the preceding few days prior to their presentation.
• 2:47
  SPEAKER_02: That helps us identify patients who may pose an infectious risk to our other patients and also our staff.
• 2:54
  SPEAKER_02: We also ask patients about other exposures.
• 2:57
  SPEAKER_02: So exposures to sick contacts and also travel.
• 3:01
  SPEAKER_02: And we utilize a universal travel screen, and then we're able to kind of parse out to depending on the risks in the locations of interest.
• 3:10
  SPEAKER_01: Are there any interventions that take place upon a positive screening result, such as, you know, is a patient moved to like a different area of triage or the waiting room or in the ED?
• 3:20
  SPEAKER_01: Is the patient placed on transmission-based precautions?
• 3:23
  SPEAKER_02: Yep.
• 3:24
  SPEAKER_02: So that's the purpose of really asking these questions is hopefully to have an intervention.
• 3:28
  SPEAKER_02: Now, of course, emergency departments are busy, hectic places.
• 3:32
  SPEAKER_02: So I hope that this is what's happening.
• 3:35
  SPEAKER_02: But I certainly think that there's always room for improvement at every institution.
• 3:40
  SPEAKER_02: But so if a patient screens positive for any of those symptoms that might flag a specific uh risk of having a transmittable infectious illness, they will be at a minimum placed in a mask and potentially immediately roomed should we have the bed and room capacity available.
• 3:58
  SPEAKER_02: During periods of like higher infectious risk, for example, right now in our respiratory virus season, we may keep patients sort of separated in the waiting room to prevent patients who may be potentially infectious from being in contact with patients who aren't infectious.
• 4:14
  SPEAKER_02: Additionally, for patients who we are concerned about having a potentially transmittable infectious illness, we can also order precautions.
• 4:23
  SPEAKER_02: There are transmission-based precautions on the patient in the electronic medical record, and that will flag them on our trackboard as a patient who we need to make sure that we're paying attention to the precautions and taking care of them appropriately.
• 4:36
  SPEAKER_02: If they flag from an exposure or a travel history perspective for a potentially serious communicable disease, like a viral hemorrhagic fever, something like that, of course, there's an algorithm that we follow for that.
• 4:49
  SPEAKER_02: And that information is taken to the charge nurse and the charge attending in the emergency department and then escalated to hospital leadership and infection prevention to identify further risk.
• 5:00
  SPEAKER_01: Thank you so much for the thorough response, Anna.
• 5:02
  SPEAKER_01: And John, what happens at your institution?
• 5:04
  SPEAKER_00: Well, we have a very busy emergency department, as you know, Chad, and very little room for putting people where they really ought to be.
• 5:14
  SPEAKER_00: But we do screen for everybody who comes to the triage window gets asked a series of questions about what symptoms they're having.
• 5:23
  SPEAKER_00: And if they have, for example, a cough, they're immediately given a mask and asked about other symptoms.
• 5:30
  SPEAKER_00: Person who's vomiting, for example, would be roomed immediately if there's a room.
• 5:35
  SPEAKER_00: And they're asked about travel in the last 30 days.
• 5:38
  SPEAKER_00: And I don't know about other places, but we have an EPIC screen that um includes specific pop-up links to CDC uh travel warnings.
• 5:48
  SPEAKER_00: So if there's a if a person says they've traveled to a specific country where there's a warning, then that triggers a process for dealing with that.
• 5:56
  SPEAKER_00: The devil's in the details though, because you know you it requires the the person who's asking the questions to ask them in a in a way that elicits a response that is both truthful and meaningful and useful.
• 6:11
  SPEAKER_00: Um sometimes you have people coming in that don't really know what's going on.
• 6:15
  SPEAKER_00: Maybe they don't come to the triage window, they come in through an ambulance and may not be able to answer those questions.
• 6:21
  SPEAKER_00: So although you have a screening process, there are a lot of holes in it, uh, I would say that are a real challenge for making a screening process.
• 6:32
  SPEAKER_00: It's not airtight or watertight.
• 6:34
  SPEAKER_00: But you know, a person who's reading a list of questions and gets a pop-up, if they're busy, they may just dismiss that pop-up.
• 6:42
  SPEAKER_00: So there's lots of issues, I think, with uh the completeness of screening in the ER that make it challenging.
• 6:49
  SPEAKER_01: Thanks for pointing out some of the nuance associated with asking these questions.
• 6:52
  SPEAKER_01: Uh John, how do you think screening practices can be improved?
• 6:55
  SPEAKER_00: Yeah, that's a very good question.
• 6:57
  SPEAKER_00: I think there's a very important to have someone who is at the triage desk who is informed and educated about what you're looking for.
• 7:06
  SPEAKER_00: If you have a a clerk at the deck at the front desk who is not a uh an RN or has no medical training, then the screening is not as good.
• 7:17
  SPEAKER_00: And so you we have to make sure that we're training and providing the staff to staff the triage window and educate them about what you're looking for and why you're looking for it.
• 7:28
  SPEAKER_00: So I think training and staffing are the the real things that we we struggle with and need to focus on.
• 7:35
  SPEAKER_01: And Anna, what are your thoughts?
• 7:37
  SPEAKER_02: Yeah, I think John's exactly right on that.
• 7:39
  SPEAKER_02: There are there are lots of opportunity for improvement to best practices.
• 7:44
  SPEAKER_02: I think a couple um things that I face in the emergency department.
• 7:49
  SPEAKER_02: One is exactly as you said, when our patients first arrive, they're screened by sort of like a frontline person as soon as they walk in the door and to get their initial chief complaint, and then they're brought back for a more comprehensive triage.
• 8:03
  SPEAKER_02: And that there's signs asking patients to self-identify those symptoms and exposures, but conceivably they may not be asked about them until they actually make it to triage.
• 8:15
  SPEAKER_02: So they may be sitting in the waiting area waiting for that triage process for a little bit of time before they're fully identified if a patient doesn't self-identify, which of course many can't.
• 8:25
  SPEAKER_02: And there are, as John pointed out, other um methods of presentation into the emergency department.
• 8:31
  SPEAKER_02: So I think healthcare training of our frontline providers, our nurses, our triage checks, our registration to identify potential patients with a transmittable illness are important.
• 8:44
  SPEAKER_02: But I think uh the other thing is that we in the emergency department are asked to do so much screening.
• 8:52
  SPEAKER_02: It's not just about these symptoms, travel exposures, things like that.
• 8:57
  SPEAKER_02: Patients are screened for suicide risk, fall risk, safety at home, many, many screenings.
• 9:03
  SPEAKER_02: And these um triage can really take a lot of time.
• 9:06
  SPEAKER_02: So I think that there is some level of alert fatigue, triage fatigue that I think needs to be addressed.
• 9:12
  SPEAKER_02: And we need to be very um diligent about reinforcing the importance of these screens so that they're done appropriately and correctly 100% of the time.
• 9:22
  SPEAKER_02: The other thing I was just going to mention is that a lot of these screens are focused on immediate threats to infectious transmission in to our other patients and to our staff.
• 9:33
  SPEAKER_02: But I don't think we often think of the larger public health context in some of these screenings.
• 9:39
  SPEAKER_02: So, for example, there's not a lot of screening for multidrug resistant organisms, things like that that are a little bit more of a chronic exposure risk or more pose a risk at the population level in our emergency department, but I think are going to become more and more important as we um see patients with extensively resistant organisms and something that we have an opportunity to impact in the emergency department.
• 10:04
  SPEAKER_00: You know, one other thing that we can do to improve things is to run simulations of the process.
• 10:09
  SPEAKER_00: And we have done that, to run training exercises that, for example, we at one point during the Ebola epidemic, we had some actors come in and pretend to have uh traveled to West Africa and sort of tested the response and then learn from those responses.
• 10:28
  SPEAKER_00: So testing the system through simulations, I think, is is something that can help improve the screening process.
• 10:35
  SPEAKER_00: It doesn't always yield the response that you would like.
• 10:39
  SPEAKER_00: Uh, and and so finding your mistakes and patching those holes is an important step.
• 10:44
  SPEAKER_02: We find those drills to be hugely beneficial.
• 10:47
  SPEAKER_02: So it always, even if we think our processes are really buttoned up, we really find opportunities for improvement, whether that's like in how we're um moving a patient through our emergency department, how we're identifying them, who needs to be notified, things like that.
• 11:02
  SPEAKER_02: I think those drills are very revealing and should be done in a culture of safety so that people feel comfortable to make those mistakes so we can learn from them and make improvements.
• 11:14
  SPEAKER_00: The challenge, though, is always the time and energy and money that you put into those kinds of training exercises.
• 11:23
  SPEAKER_00: When the emergency departments are functioning at 110% of capacity around the clock all the time, it's really hard.
• 11:33
  SPEAKER_00: And uh so the hospital administrators need to be aware of the issue, how strapped emergency departments can be and how how that can affect what happens in the rest of the hospital.
• 11:46
  SPEAKER_02: Yeah, no administrator wants to come in for the drill at 4 a.m., you know, when it's a little bit of a low for us.
• 11:52
  SPEAKER_01: Great.
• 11:53
  SPEAKER_01: Thank you both for the interesting dialogue.
• 11:54
  SPEAKER_01: Anna, how are transmission-based precautions used in your ED and are there differences when compared to inpatient areas?
• 12:01
  SPEAKER_02: So, as I was mentioning, we use an electronic medical record-based designation for our patients who we want to put in transmission-based precautions, anything from contact droplet, airborne isolation.
• 12:14
  SPEAKER_02: Um, and then we attempt to adhere to those to the best of our ability.
• 12:19
  SPEAKER_02: I would say that one thing we struggle with in emergency departments in general is in airborne isolation patients.
• 12:27
  SPEAKER_02: Most emergency departments just don't have enough true airborne isolation rooms, and we're always short of beds.
• 12:35
  SPEAKER_02: And so we may have a non-airborne isolation patient in an airborne isolation room.
• 12:40
  SPEAKER_02: And then when we have a patient that needs to go into that room, it takes some time to clear the room, clean it, get it ready for that patient.
• 12:47
  SPEAKER_02: So I think that that's something that, of course, hindsight is great for the inpatient team where they already know that information, they're able to clear a bed for those patients and have them in the ideal circumstance.
• 13:01
  SPEAKER_02: But for us in the emergency department, sometimes it's more doing the best we can, making sure they're in a room with a door, making sure we're wearing our respirators, things like that for those patients.
• 13:12
  SPEAKER_02: The other thing is just with the bed shortages in general, we do board a lot of our admitted patients until they get rooms in the hospital.
• 13:20
  SPEAKER_02: And so that just front loads our emergency department in terms of our new patients having space to be seen and then be cared for.
• 13:28
  SPEAKER_02: And so sometimes I think that is in detriment to patients who may have a transmittable infectious disease, where they're in a curtained room or in a hall stretcher, which is, of course, as we know, not an ideal location to care for some of these patients, but we're just doing the best we can and making sure that as much as we can, we're in RPPE, masking our patients.
• 13:50
  SPEAKER_02: I do think this needs to remain a priority, but I think in the emergency department also, we have so many competing demands in a rapidly changing environment that sometimes it's hard to prioritize some of these precautions versus taking care of a critical resuscitation.
• 14:09
  SPEAKER_02: And I think that's something that on the inpatient side, they have a little bit more time and understanding and a true knowledge of what's going on with the patient that we don't have.
• 14:19
  SPEAKER_02: And so I think that that's something why we always need to be even reinforcing this more and more because we need to be careful and be prepared for anything for our patients.
• 14:30
  SPEAKER_01: And John, would you like to respond?
• 14:32
  SPEAKER_00: One of the things that's a particular challenge in terms of following transmission-based precautions in the emergency department nowadays is the amount of time that uh patients spend in the emergency department.
• 14:44
  SPEAKER_00: So contact precautions are really sort of designed to prevent transmission over time in the hospital and less emphasized in outpatient areas where patients spend a very short period of time.
• 14:57
  SPEAKER_00: But when you have people boarding in the emergency department for sometimes two or three days on a stretcher in the hallway, then you really need contact precautions perhaps to help prevent that transmission.
• 15:10
  SPEAKER_00: So I think the most important thing for an emergency department is to really hit home on standard precautions and to make sure that everyone really understands what standard precautions means.
• 15:24
  SPEAKER_00: A lot of people kind of have the impression that standard precautions means I don't need to do anything, but it it's much, much more than that.
• 15:31
  SPEAKER_00: And if we do focus on standard precautions, making sure that when there's a lot of contact with a patient, that you're putting on a gown and gloves, if you're having contact with blood or body fluids, you're putting on gown and gloves and eyewear, putting a mask on a patient who's coughing, you know, things like that, and hand hygiene, then transmission will be minimized.
• 15:52
  SPEAKER_00: And the other thing is environmental cleaning.
• 15:55
  SPEAKER_00: If you can hire enough cleaning staff, you can increase the frequency of environmental cleaning, which will help compensate for breaches in transmission-based precautions.
• 16:06
  SPEAKER_00: One of the things that our ER has been piloting is a new use of a new type of cleanser that's sporicidal.
• 16:14
  SPEAKER_00: And so using a sporosidal cleaner and increasing the frequency of cleaning might be able to compensate to some degree for lack of adherence to contact precautions.
• 16:24
  SPEAKER_00: The issue of airborne precautions is a bigger challenge.
• 16:28
  SPEAKER_00: And uh, best you can do is put a mask on the patient who's coughing in that kind of situation.
• 16:33
  SPEAKER_00: But when it goes on for a long time, there's not a whole lot you can do.
• 16:37
  SPEAKER_01: And I think this leads nicely into our next question.
• 16:39
  SPEAKER_01: Uh John, what are your thoughts on the use of transmission-based precautions based on laboratory identification or like a history of a known pathogen versus syndrome-based precautions for patients, particularly in the ED, such as the contact precautions for the patient with a large wound in uncontained secretions?
• 16:56
  SPEAKER_00: Well, the way we've written our contact precautions policy is if someone has a large wound, open wound, um, they they're supposed to be put in contact precautions.
• 17:05
  SPEAKER_00: So, but the exception that you actually know what a person is colonized with in the emergency department, some people come in with a flag on their chart from a previous hospitalization, but unless you dig deep into the chart, you may not know when a person is colonized with the resistant organism.
• 17:24
  SPEAKER_00: So using really, really good standard precautions and using a barrier that's appropriate to the situation is the thing that's going to prevent transmission, I think.
• 17:35
  SPEAKER_01: Anna, do you have any thoughts?
• 17:37
  SPEAKER_02: Yeah, I mean, I really agree with um what John said in the emergency department.
• 17:42
  SPEAKER_02: We often just don't have the diagnoses for our patients.
• 17:45
  SPEAKER_02: So it really has to be syndrome-based.
• 17:47
  SPEAKER_02: So we really need to be identifying these wounds, these secretions, respiratory illness, fevers, whatever it is, and making an educated decision based on those symptoms and syndromes.
• 18:00
  SPEAKER_02: I do really like the electronic medical record-based flags for patients that are colonized with multidrug resistant organisms.
• 18:09
  SPEAKER_02: I think that's really helpful to know.
• 18:12
  SPEAKER_02: But I do think there needs to be a bit of a culture change in emergency medicine and in practitioners in the emergency department about what to do with those patients.
• 18:22
  SPEAKER_02: I think that it is best practice to use standard precautions, gown, glove, mask, eye protection for these situations, but that's not a historical emergency department culture.
• 18:35
  SPEAKER_02: And I think that that is unfortunate and we need to change it because I think moving forward into the future, we're going to see more and more impact from some of these organisms.
• 18:45
  SPEAKER_02: And so having ready access to PPE, making it really easy to put on a gown and change it, and there's space to don and doff, and the trash cans emptied so you can put your gown in and all those things to facilitate the ease of the standard precautions, I think is really important.
• 19:04
  SPEAKER_00: Chad, that was something you worked on, uh, wasn't it?
• 19:07
  SPEAKER_00: Making PPE available and in places where previously PPE was only available when a person had a contact precaution sign and a cart, making PPE available at just about every patient's door is really important, making it easy to use.
• 19:22
  SPEAKER_01: You're absolutely right, John.
• 19:23
  SPEAKER_01: It was a project that I was particularly passionate about years ago.
• 19:26
  SPEAKER_01: Thank you for that.
• 19:27
  SPEAKER_01: Do either of you have any tips for maintaining compliance with PPE in the ED?
• 19:31
  SPEAKER_02: Well, that's a million-dollar question.
• 19:34
  SPEAKER_02: Um, I think that it's exactly what we were saying, making the PPE available and easy to use and comfortable for people.
• 19:45
  SPEAKER_02: I think that we learned a lot during COVID, during the pandemic, about what people felt comfortable to do and what risks people were willing to take.
• 19:55
  SPEAKER_02: And I think that practitioners in the emergency departments really got more comfortable with PPE, which I think is a good thing.
• 20:04
  SPEAKER_02: Um, but I think also it led to some complacency as the pandemic dragged on.
• 20:10
  SPEAKER_02: But I think having it readily available, easily accessible at patients' bedsides, easy to don and doff, and something that's uh not unfamiliar, I think is the most important thing.
• 20:22
  SPEAKER_02: We don't want to constantly be reinventing the wheel.
• 20:26
  SPEAKER_02: Once we find something that's great, let's just keep it so it's available.
• 20:30
  SPEAKER_02: I do think given the rapid turnover in the emergency department, it's sometimes hard to kind of continue to update the signage and things like that.
• 20:39
  SPEAKER_02: And I think that's something that's an opportunity for improvement because when we leave PPE at bedside, then it becomes unclear for when people really need to be wearing it.
• 20:50
  SPEAKER_02: Certainly they should be wearing it all the time.
• 20:52
  SPEAKER_02: The reality is they're not going to be.
• 20:53
  SPEAKER_02: So having that visual cue is important.
• 20:56
  SPEAKER_02: So if there's something that really triggers providers to say, okay, I need to put this on, and it doesn't just become another notification fatigue episode, I think that that is also really important.
• 21:10
  SPEAKER_02: And I think one thing that I found to be really helpful is just to continue to educate everybody about what's going on, why this is important.
• 21:18
  SPEAKER_02: I think it's easy for people to forget the importance of what we do and the risk to ourselves, to our families, to our other patients.
• 21:27
  SPEAKER_02: And so continuing to kind of share a landscape of what's happening in our region, in the world, and why we ask these questions, why we put on our PPE, I think that that often I find really rings true for a lot of people.
• 21:40
  SPEAKER_02: And then modeling it ourselves.
• 21:42
  SPEAKER_01: Very well said.
• 21:43
  SPEAKER_01: John, did you have anything to add?
• 21:45
  SPEAKER_00: Yeah, I mean, one of the things that we've tried to promote is um using the hand hygiene moment before going into a patient's room as a mindful moment to ask the question in what I'm about to do.
• 22:00
  SPEAKER_00: How might I or this patient or someone else in the room be harmed?
• 22:05
  SPEAKER_00: And so using that period of when you're washing your hands as a mindful moment because the pace of things in the emergency department is so rapid and the culture is one, I think, of heroism and wanting to do everything fast and quick and get in there and do it right.
• 22:24
  SPEAKER_00: And so part of that heroism ethos needs to be taking the time to anticipate how a harm might occur as a result of your action.
• 22:34
  SPEAKER_00: So that's something that we tried to preach.
• 22:36
  SPEAKER_00: I don't know how well it's penetrated, but I think if we had more time to do training sessions, that that would help.
• 22:43
  SPEAKER_00: The other thing that has been done in RER is that they they do video recordings of trauma resuscitations and then critique each other following those in sort of debrief and including use of PPE as part of that debriefing process.
• 23:00
  SPEAKER_00: How did you use it?
• 23:00
  SPEAKER_00: Did you make a breach and you know that kind of thing?
• 23:03
  SPEAKER_00: So I think video recording can be a helpful tool to help improve compliance.
• 23:08
  SPEAKER_01: John, what were some of the structural or practice-related weaknesses identified during the pandemic that resulted in suboptimal infection prevention measures?
• 23:16
  SPEAKER_00: The main thing was that we didn't have enough airborne rooms, and I think that's already been discussed, and just not enough room period for all the people.
• 23:25
  SPEAKER_00: So one of the things that we had to do was we took an entire auditorium that was adjacent to the emergency room and rapidly converted that into a separate holding area.
• 23:37
  SPEAKER_00: And we had to work on creating negative airflow for that entire new building that went up in a matter of days.
• 23:45
  SPEAKER_00: Not a new new building, but a rework of an existing building.
• 23:48
  SPEAKER_00: And so, you know, just having the space and uh enough negative pressure rooms, we really are not set up in our medical system to take on a large-scale airborne event where people are transmitting things by airborne route.
• 24:03
  SPEAKER_00: That's why everybody was wearing an N95 mask all the time, because uh we couldn't sequester people in uh places where they uh would not be transmitting things.
• 24:13
  SPEAKER_00: The other, you know, weakness really is just the amount of space that we have.
• 24:17
  SPEAKER_00: And there's just not not enough and not enough staffing either.
• 24:22
  SPEAKER_00: So those are things that really get in the way.
• 24:24
  SPEAKER_01: Anna, is there anything you'd like to add?
• 24:26
  SPEAKER_02: The main thing that really made it challenging was in-provider burnout.
• 24:31
  SPEAKER_02: Having worked in the emergency department all throughout the pandemic, it was really emotionally and physically tough on providers.
• 24:39
  SPEAKER_02: We had a lot of changes in staffing, we lost a lot of nurses to other opportunities.
• 24:46
  SPEAKER_02: And that constant stress of the pandemic, I think, really led to practices breaking down in some of these infection control moments.
• 24:56
  SPEAKER_02: I think that we learned throughout the pandemic that in something like this, if we are compliant with our transmission-based precautions, with our PPE to the best of our abilities, we are pretty good at preventing transmission to ourselves, to our other patients, even despite the space constraints, despite not having the appropriate airborne rooms, things like that.
• 25:20
  SPEAKER_02: But when you add the component of that fatigue and that burnout to it, that's when those mistakes can happen.
• 25:28
  SPEAKER_02: And so I think that moving forward, hopefully we're in a better position from staffing and understanding of uh the landscape of what's at risk for us.
• 25:39
  SPEAKER_02: But I think that kind of continuing to focus on provider well-being uh, I think is really important in these scenarios.
• 25:47
  SPEAKER_01: Anna, how do you foresee ED's changing to manage patients with suspected or confirmed organisms of public health significance?
• 25:54
  SPEAKER_02: I hope that we continue to learn from these experiences, from the experiences of the past, and uh move forward with a more um holistic approach to our patients with suspected or confirmed transmission-based organisms.
• 26:09
  SPEAKER_02: I hope that we get better about identifying these patients upfront, kind of what we were talking about in terms of having universal screens that enhance our triage process, and that we actually have actionable items related to our screens, masking patients, separate split triage flows, split waiting rooms, uh, getting patients rapidly into rooms, and then getting our staff informed to see the importance of doing this.
• 26:38
  SPEAKER_02: I think that the other thing that will be great is people like you going into emergency medicine who have background in public health and a background in infection control and see the importance of this because I do think because emergency medicine is such a new specialty, and because we are focused on caring for all types of conditions, anytime, anyplace, uh 24-7, that this is just one of the many things that we learn and one of the many things that we practice.
• 27:05
  SPEAKER_02: And I think that the more that we have these conversations and that we bring this up and that we have experiences where we live these things real time or in drill form, that will just help us better solidify these practices.
• 27:21
  SPEAKER_02: And then the other thing I'll say is that emergency medicine is a pretty um algorithmic-based specialty.
• 27:28
  SPEAKER_02: We like algorithms, we like to have those.
• 27:31
  SPEAKER_02: And I think that the more that the hospitals place an emphasis on developing protocols and procedures for what to do, then the more the practitioners in the emergency departments will feel comfortable to make sure that we're doing the right thing because we have that backing, that support, and we know what the next step is.
• 27:51
  SPEAKER_01: Thanks, Anna.
• 27:52
  SPEAKER_01: John, same question to you.
• 27:53
  SPEAKER_01: What are your thoughts?
• 27:54
  SPEAKER_00: Well, what I'd like to see is that emergency departments are constructed and rebuilt to really have a much greater surge capacity than they have now.
• 28:05
  SPEAKER_00: We have such limitations on at least where we are, it's not possible to suddenly create a tent outside.
• 28:14
  SPEAKER_00: The landscape doesn't allow it.
• 28:16
  SPEAKER_00: And so to have structures within the hospital that allow the emergency department to expand to meet the number of people that are coming to the emergency department is something that hospital building planners need to think about, I think.
• 28:30
  SPEAKER_00: And then creating the right uh biosafety systems within those new structures, for example, having enough negative pressure rooms available or other systems that allow you to prevent transmission.
• 28:44
  SPEAKER_00: The days of having, you know, four or five people lined up in a hallway coughing really should be in the past.
• 28:53
  SPEAKER_00: We shouldn't have that.
• 28:54
  SPEAKER_00: We need to have enough space in the emergency department to separate people who have communical conditions and enough staffing to take the time to do things properly, then build the safety culture within the culture of heroism, to build the culture of safety that allows us to prevent transmission to ourselves and to other patients.
• 29:16
  SPEAKER_00: I think those are the main things that I think would be helpful in preventing transmission in the emergency department going forward.
• 29:23
  SPEAKER_02: I do a lot of work in emergency medicine capacity building internationally.
• 29:29
  SPEAKER_02: And it's really cool because emergency care is such a new field of medicine all over the world, including in the US.
• 29:37
  SPEAKER_02: And I think that we all face the same challenges with this topic and many other topics.
• 29:43
  SPEAKER_02: And I think it really has to come down to the people that work in the training, um, people that work in the emergency department, because we don't know what the next thing is.
• 29:53
  SPEAKER_02: And so it might not be a respiratory illness, it might be something else.
• 29:57
  SPEAKER_02: We need to just have a culture of standard precautions and a culture of paying attention to kind of these threats and making informed decisions.
• 30:07
  SPEAKER_02: And I think that it doesn't matter what resources that we have, whether we have all the state-of-the-art ability to have like every room in our emergency department with airborne isolation and everyone can be in a pamper, you know, taking care of these patients, to, you know, not even having gowns, which we see we saw during the pandemic, um, and so many places um in previous pandemics, viral hemorrhagic fevers and other things in different parts of the world saw.
• 30:37
  SPEAKER_02: But I think the um the uniting event is healthcare worker awareness, too, and attention to those details and care, even the most basic of PPE.
• 30:49
  SPEAKER_02: And I think that that is gonna be what saves us in the future.
• 30:54
  SPEAKER_00: I agree with that 100%.
• 30:56
  SPEAKER_00: Um I also and our experience here is such that our emergency room is so crowded and people are spending such a long time in the in the emergency department that matching the emergency department capacity for a city with the demand is an important factor in in hospital planning.
• 31:17
  SPEAKER_00: And uh, I don't think we've caught up with the expansion of the the nature of the problems that are there.
• 31:24
  SPEAKER_00: And uh so the longer a person spends in the emergency department, the greater the possibility of transmission in the emergency department is.
• 31:32
  SPEAKER_00: So it's not only just changes in the emergency department, but also changes in the community care.
• 31:37
  SPEAKER_00: Because if patients can't get care from their primary care doctor, they can't get discharged from a hospital.
• 31:44
  SPEAKER_00: So that makes people getting discharged a problem, that makes people moving through the emergency department a problem.
• 31:50
  SPEAKER_00: So it's really a holistic kind of solution that involves improving elder care, improving community primary care and access to primary care, and then improving the flow of patients through the emergency department that that will help.
• 32:07
  SPEAKER_02: The flow through the whole hospital and even exactly transport home.
• 32:12
  SPEAKER_02: I mean, that's a major choke point for us right now.
• 32:15
  SPEAKER_02: It's just not even having enough transporters available to get patients home and they stay in the hospital extra days.
• 32:21
  SPEAKER_02: So it it unfortunately, I think to fix this issue will require a whole healthcare system overhaul in some ways.
• 32:30
  SPEAKER_00: We shouldn't shy away from that overhaul, I don't think.
• 32:33
  SPEAKER_02: No, definitely not.
• 32:35
  SPEAKER_01: Thank you both for such a fantastic conversation.
• 32:37
  SPEAKER_01: We appreciate you joining us today.
• 32:39
  SPEAKER_02: Thanks for having us.
• 32:40
  SPEAKER_00: Yeah, it was a pleasure to speak with you, Chad.
• 32:43
  SPEAKER_00: Hope we can do it again soon.
• 32:44
  SPEAKER_01: You can find more educational content like this podcast on Shay's online education center, Learning CE, at www.learningce.shayonline.org.
• 32:55
  SPEAKER_01: This concludes today's episode of the developments in transmission based precaution series.
• 32:59
  SPEAKER_01: Thank you for tuning in.